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Sunday, October 03, 2004

ED Congestion and Dissolving Boundaries

As I have followed recent press articles about overcrowded hospital Emergency Departments (ED’s), my thought has been that the obvious solution was to expand them.

Apparently I was wrong. (No surprise. It has happened before.)

The Summer 2004 issue of Frontiers of Health Services Management features the Institute for Healthcare Improvement (IHI) and the techniques it has developed for improving flow through acute care settings, in this case, ED’s. In applying these techniques, IHI has found that ED’s are being clogged up less by what comes in their front doors than by what they are unable to move out the back. So expansion won’t help. Enlarging the entry doesn’t shorten the queue at the exit.

The problem is expressed in terms of variation, three types of which are identified:

First, there is variation in the numbers, arrival times, and conditions of patients coming for care. Second, there is variation in staff competency and clinical abilities. These two are called natural variation. They are inherent in any situation and are to be managed.

The third type of variation arises “from personal preferences and beliefs of individual clinicians.” The authors call this artificial variation and say that it needs to be eliminated. They say “The effect of artificial variation on flow far exceeds the effect of variation resulting from random, highly complex disease presentations.”

In other words, the hospital (including its medical staff) is the source of the problem, not the patients.

Two cases are then described in which application of the IHI techniques has successfully relieved ED congestion.

What I found striking in all of this was the absence of deference to the special status of doctors and the lack of respect for the traditional boundary that prevents hospital management from interfering in medical matters. Particularly audacious was the blunt statement that variation in the preferences and beliefs of individual doctors needs to be eliminated! (emphasis mine) It hasn’t been long since a remark like that could get somebody fired.

This may well be the best example yet of how the health care system must learn to manage the patient care process as a totality; i.e., including the practice of medicine, if it is to successfully control cost and achieve uniformly high levels of quality.

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